Infection, Wounds, and SIRS in

surgery

Graeme MacLaren

MBBS FCICM FRACP FCCP

Director, Cardiothoracic ICU

Assistant Professor of Surgery
National University Health System, Singapore

Prcis
Natural barriers to infection
Effects of surgery
SIRS and sepsis
Prevention

Barriers to Infection
Part of innate immunity
Skin
Stronger in hands and feet
Sebaceous secretions lower pH
Mucous membranes
Ciliary function
Mucous barrier
Proteolytic enzymes eg. lysozyme
Acid milieu in stomach

Barriers to Infection
Commensal enteric bacteria
Important for immune development
Occupy binding sites for pathogens
Provide mucobacterial barrier
Anaerobic bacteria

present in greatest quantity in gastrointestinal tract

diverse
prevent invasion by Gram negative aerobes

Immune defense
Innate immunity
Basic polypeptides
Complement
Natural killer cells
Humoral defense (B-cell immunity)
Cellular defense (T-cell immunity)

Breakdown of host defense

Patient factors
Chronic illness

Diabetes
End-stage renal failure

Immunosuppression

Steroid use
Immunosuppressant therapy, eg. cyclosporin

Malnutrition

malignancy

Breakdown of host defense

Surgery
Bypasses host defenses via controlled trauma SIRS
May alter anatomy or blood supply permanently
Perioperative antibiotics kill commensal enteric flora
Associated medical devices

central venous lines

urinary catheters
mechanical ventilation
nasogastric tubes

Bypass of host defenses

Nasogastric tube:
Impairs sinus drainage,
potentiating sinusitis

Endotracheal tube:
(only pilot balloon visible)

Impairs coughing,
ciliary function,
increases % of
pneumonia

Pulmonary artery
catheter (central
venous catheter):
Provides portal of entry
into bloodstream

Definitions
Systemic inflammatory response syndrome (SIRS)
Common response to surgery
Diagnosed when >1 of the following are present:
Body temperature <36 or >38
Heart rate > 90 bpm
Respiratory rate >20 or PaCO2 <32
White blood cell count <4 or >12

Definitions
Sepsis is defined as
SIRS due to infection
Severe sepsis is
sepsis with organ dysfunction, hypoperfusion, or
hypotension
Septic shock is
severe sepsis with arterial hypotension despite adequate
fluid resuscitation

SIRS
Common pathophysiological response to a host of

triggers, eg. surgery, infection, trauma, pancreatitis,

burns, cardiopulmonary bypass
Mediated by a host of cytokines, including
IL-6
Adrenomedullin
sCD14
sELAM-1
MIP-1
Extracellular phospholipase A2
C-reactive protein

Manifestations of infection
Local
Pain
Erythema
Swelling
Warmth
Systemic
Fever or hypothermia
Tachycardia
Tachypnoea
Vasodilation and hypotension

Types of wounds
1. Clean - no viscus, no sterile breach
2. Clean contaminated - controlled entry into viscus
3. Contaminated eg. emergency bowel resection,

perforated appendix

4. Dirty - heavy contamination / long duration

Antibiotics used for prophylaxis in all

Antibiotics used for treatment in 3. and 4.

Common post-surgical infections

Pneumonia
Ventilator-associated or not
Exact definition difficult, no gold standard
Presence of SIRS, worsening pulmonary infiltrates, productive
sputum consistent, but not 100% specific
More common in patients with

Prolonged ventilation
Upper abdominal surgery
Major thoracic surgery
Thoracoabdominal trauma
Poor post-operative analgesia

Common cause of death; needs aggressive treatment with

appropriate anti-microbials (including anti-pseudomonal + antistaph)

Common post-surgical infections

Urinary tract infection (UTI)
Not especially common, except after urological surgery.
Important to distinguish between asymptomatic catheterassociated bacteriuria (CA-ASB) and genuine UTI. Catheterassociated UTI is:

Presence of signs of symptoms compatible with UTI

No other identified source of infection
>10x3 cfu/ml of bacteria

CA-ASB is:

>10x5 cfu/ml of bacteria

No symptoms of UTI

(IDSA guidelines, 2010)

Note that pyuria not useful in discriminating between them

Common post-surgical infections

Vascular catheter-associated infection
Most common with central venous catheters (CVC), also
seen with arterial lines and IV cannulae. Most important
determinants is efficacy of sterility of insertion and how
long they are left in
No evidence that routinely changing CVCs is of benefit,
unless they appear infected or the patient has SIRS with
no obvious cause
All peripheral cannulae should be changed every 48-72
hours

Common post-surgical infections

Surgical site infection (SSI)
Superficial vs Deep
Superficial easily diagnosed

often respond to appropriate wound care and may not require

systemic antibiotics unless surrounding cellulitis, artificial
material used during surgery, or SIRS present

Deep is harder to diagnose. May just manifest as SIRS

without obvious focus

May require imaging (eg CT scan) or surgery (eg. repeat

laparotomy) to diagnose, depending on the site of surgery
Treatment always involves re-operating AND systemic
antibiotics

Treatment of SSI
Incise and drain pus
Antibiotics (depends on the type of surgery)
Debride devitalized tissue
Remove foreign bodies

Prevention of SSI: Asepsis

Topical anti-septics, eg. chlorhexidine
Thorough washing and gloving
Sterile drapes
Meticulous surgical technique
Hair removal: often unnecessary. Clip, dont shave

Prevention of SSI: Antibiotics

Prophylactic antibiotics before skin incision shown to

reduce SSI significantly

Use antibiotics appropriate to the site of surgery, eg.
cephazolin for skin organisms; ampicillin, gentamicin,
metronidazole for bowel surgery.
Limit to intra-operative dosing, or <24 hours if clean
surgery
Avoid broad-spectrum agents

Prevention of SSI: Other measures

Maintain good control of blood sugar (eg. 4-8 mmol/L,

though ideal levels controversial, extremes should

definitely be avoided)
Perioperative normothermia
Other measures are controversial, including
Supplemental oxygen to decrease infection
Skin stapling vs suturing
Leucocyte filters on allogeneic blood products

Example
A 57 year old with a 20 year history of poorly

controlled diabetes undergoes a right hemicolectomy

for an adenocarcinoma of the colon. He has been
recovering well post-operatively. On POD 7, you are
called to see him as he feels unwell and the nurse
reports fever. Vital signs are:
Temp 39
Heart rate 135
BP 80/40
Respiratory rate 22

What do you do?

Suggested approach
Resuscitate: A, B, C
Notify seniors
Blood cultures
Other septic workup, eg. MSU, sputum, if possible
Brief targeted history, eg. symptomatology
Comprehensive physical examination
CXR
Start appropriate antibiotics
Further investigations as directed by assessment, eg CT
abdomen
Likely differentials: SSI, Hospital-acquired pneumonia
Much less likely but worth considering: UTI, IV infection,
DVT/PE (extremely unlikely, but life-threatening),
pseudomembranous colitis, epidural site infection, etc

The end